5-Tier Preferred Drug List - Health Plan of Nevada

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metaproterenol tablets *ALUPENT (tablets) 1montelukast *SINGULAIR 4mg 1 QL (30 tablets/month)montelukast *SINGULAIR 5mg 1 QL (30 tablets/month)montelukast *SINGULAIR 10mg 1 QL (30 tablets/month)montelukast *SINGULAIR 4mg Granules 2 QL (30 packets/month)mometasone-formoterol inhalers DULERA 3 STDulera ST = (asthma) requires 60 day therapy of ICS or Symbicort in past 2 years;(COPD) requires 60 day therapy of LABA, Spiriva or Symbicort in past 2 yearspirbuterol inhaler MAXAIR 3 QL (2 inhalers/month)roflumilast DALIRESP 3 PA QL (30 tablets/month)salmeterol inhaler SEREVENT DISKUS 3 QL (1 inhaler/month)salmeterol-fluticasone inhaler ADVAIR 3 QL (1 inhaler/month) STAdvair ST = (asthma) requires 60 day therapy of ICS or Symbicort in past 2 years;(COPD) requires 60 day therapy of LABA, Spiriva or Symbicort in past 2 yearssodium chloride soln nebu 7% HYPER-SAL NEBULIZER 2terbutaline *BRETHINE 1theophylline 1theophylline SLO-PHYLLIN 2theophylline THEOLAIR 2theophylline CR *UNIPHYL 1theophylline SR THEO-24 3tiotropium inhaler SPIRIVA 2zafirlukast *ACCOLATE 112-E Steroid InhalersGeneric Name Brand Namebeclomethasone HFA inhaler QVAR 40mcg 2beclomethasone HFA inhaler QVAR 80mcg 2budesonide inhaler PULMICORT FLEXIHALER 3budesonide nebulizer PULMICORT RESPULES 0.25mg 3budesonide nebulizer PULMICORT RESPULES 0.5mg 3ciclesonide inhaler ALVESCO 3flunisolide inhaler AEROBID 3flunisolide inhaler AEROBID-M 3fluticasone inhaler FLOVENT DISKUS 3fluticasone inhaler FLOVENT HFA 3mometasone inhaler ASMANEX 2triamcinolone inhaler AZMACORT 313-A AnticoagulantsGeneric Name Brand NameTierdalteparin sodium FRAGMIN 4enoxaparin sodium *LOVENOX 1fondaparinux sodium *ARIXTRA 5 PA SIOtinzaparin sodium INNOHEP 5 PA SIO13-B Growth HormonesGeneric Name Brand NameTierQL (30 tablets/month)QL (1 inhaler/month)QL (60 tablets/month)TierNotesQL (1 inhaler/month)QL (2 inhaler/month)QL (1 inhaler/month)QL (120 respules/month)QL (60 respules/month)QL (3 inhaler/month)QL (3 inhaler/month)QL (1 diskus/month)QL (2 inhaler/month)QL (1 inhaler/month)QL (2 inhaler/month)SELF-INJECTABLE/SPECIALTY (injectable drugs)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 42NotesSIO (covered up to 21 days without prior auth)SIO (covered up to 21 days without prior auth)Notes5-Tier Drug Benefit Guide09/01/13
mecasermin INCRELEX 5 PA SIO SPsomatropin (non-refrigerated) SAIZEN 4 PA SIO SPsomatropin TEV-TROPIN 4 PA SIO SPsomatropin NUTROPIN AQ 5 PA SIO SPsomatropin NUTROPIN AQ NUSPIN 5 PA SIO SPsomatropin NUTROPIN 5 PA SIO SPsomatropin SEROSTIM 4 PA SIO SPsomatropin ZORBTIVE 5 PA SIO SPtesamorelin EGRIFTA 5 PA SIO SP13-C Hematopoietic AgentsGeneric Name Brand NameTierdarbepoetin alpha ARANESP 4 PA SIO SPeltrombopag PROMACTA 5 PA SPepoetin alfa EPOGEN 5 PA SIO SPepoetin alfa PROCRIT 5 PA SIO SPfilgrastim NEUPOGEN 4 PA SIO SPpegfilgrastim NEULASTA 4 PA SIO SPpeginesatide acetate soln OMONTYS 4 PA SIOsargramostim LEUKINE 5 PA SIO SP13-D Hepatitis C AgentsGeneric Name Brand NameTierboceprevir VICTRELIS 5 PA SPinterferon alfacon-1 INFERGEN 5 PA SIO SPpeginterferon alfa-2A PEGASYS 4 PA SIO SPpeginterferon alfa-2A PEGASYS PROCLICK 4 PA SIO SPpeginterferon alfa-2B PEG-INTRON 5 PA SIO SP STpeginterferon alfa-2B PEG-INTRON REDIPEN 5 PA SIO SP STPeg-Intron ST = requires trial of Pegasystelaprevir INCIVEK 2 PA SPREBETRON 5 PA SPROFERON A 5 PA SIO SPNotesNotes13-E Multiple Sclerosis AgentsGeneric Name Brand NameTierNotesdalfampridine AMPYRA 5 QL (60 tablets/month) PA SPdimethyl fumarate TECFIDERA 3 PA SPglatiramer acetate COPAXONE 4 PA SIO SPfingolimod GILENYA 5 PA SP STGilenya ST= requires trial to 1 formulary alternative: Avonex, Copaxone and/or Rebifinterferon beta-1A REBIF 4 PA SIO SPinterferon beta-1A AVONEX 4 PA SIO SPinterferon beta-1A AVONEX ADMINISTRATION PACK 4 PA SIO SPinterferon beta-1B BETASERON 5 PA SIO SP STBetaseron ST= requires trial to Rebifteriflunomide AUBAGIO 3 PA SIO SP13-F Osteoporosis AgentsQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 435-Tier Drug Benefit Guide09/01/13
Page 1 and 2: Preferred Drug List 5-Tier21NVHPN09
Page 3 and 4: Five-Tier Drug Benefit GuideIntrodu
Page 5 and 6: FIVE-TIER Drug Benefit GuideThis dr
Page 7 and 8: griseofulvin ultramicrosize *GRIS-P
Page 9 and 10: dapsone DAPSONE 2dornase alfa PULMO
Page 11 and 12: mycophenolate mofetil *CELLCEPT 1si
Page 13 and 14: quinidine gluconate 1quinidine sulf
Page 15 and 16: indapamide *LOZOL 1methazolamide *N
Page 17 and 18: duloxetine CYMBALTA 60mg 3QL (30 ca
Page 19 and 20: iloperidone FANAPT 3 QL (60 tablets
Page 21 and 22: ivastigmine *EXELON 1rivastigmine E
Page 23 and 24: enzoyl peroxide-adapalene EPIDUO 3
Page 25 and 26: halobetasol *ULTRAVATE 1halobetasol
Page 27 and 28: estrogens (conjugated) PREMARIN 3 Q
Page 29 and 30: medroxyprogesterone *PROVERA 1noret
Page 31 and 32: levothyroxine 1levothyroxine TIROSI
Page 33 and 34: 7-B AntidiarrhealsGeneric Name Bran
Page 35 and 36: mesalamine CANASA 2mesalamine LIALD
Page 37 and 38: APAP-hydrocodone *VICODIN ES 1 QL (
Page 39 and 40: naproxen sodium *ANAPROX 1oxaprozin
Page 41 and 42: prenatal vitamins-FE-FA *PRECARE 1p
Page 43 and 44: tobramycin-dexamethasone ophth *TOB
Page 45: triamcinolone nasal NASACORT AQ 3tr
Page 49 and 50: amlodipine-aliskiren-hctz AMTURNIDE
Page 51 and 52: isotretinoin ABSORICAitraconazole O
Page 53 and 54: Alphabetical IndexDrug Name PDL Sec
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5-Tier Preferred Drug List - Health Plan of Nevada

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